Corresponding author: Marcin Bekas, Department of Radiation Hygiene and Radiobiology, National Institute of Public Health – National Institute of Hygiene, Chocimska street 24, 00-791 Warsaw, Poland, phone: + 48 22 54 21 224, fax + 48 22 54 21 309, e-mail: mbekas@pzh.gov.pl
© Copyright Narodowy Instytut Zdrowia Publicznego - Państwowy Zakład Higieny
HOW OFTEN ARE X-RAYS USED AS DIAGNOSTIC TOOL BY
HEALTHCARE PROVIDERS IN THE MAZOVIAN PROVINCE OF POLAND
Marcin Bekas
1, Antoni K. Gajewski
2, Krzysztof Pachocki
11Department of Radiation Hygiene and Radiobiology, National Institute of Public Health – National Institute of Hygiene,
Warsaw, Poland
2Faculty of Leisure and Tourism, Józef Piłsudski University of Physical Education in Warsaw, Poland
ABSTRACT
Background. Within the medical facilities provided by state healthcare services, a universally applied technique for pa-tient diagnosis and treatment relies on ionising radiation; for example in radiotherapy and X-ray (ie. examination). Human exposure to such radiation is not however entirely free of associated health risks.
Objectives. To determine and estimate the numbers and types of X-ray based medical procedures that are performed in general and dental radiography, mammography and computer tomography on patients from the Mazovian province in Poland, which included children, women and men subjects.
Material and Methods. The numbers of patient subjects undergoing X-rays was estimated by surveying the patient intake in X-ray testing rooms within the healthcare facilities of the Mazovian province. Questionnaires were either dispatched by mail to such healthcare centres or were completed by the X-ray operating staff during the testing of quality control. Results so obtained from the latter, were compared to entries from the X-ray rooms’ register
Results. During 2009, the number of X-rays performed were 7612046 equivalent to 1460 examinations per 1000 inhabitants. The majority were done on women ie. 3847961 (50.55%), followed by 3193781 (41.96%) on men and 570 304 (7.49%) for children.
Conclusions. Results indicated that the predominating medical procedure used of this type, was for making general diag-noses; especially through using chest radiography. Others included, in descending order; dental X-ray (mainly intra-oral examination), computer tomography (mainly CT head examinations) and mammography procedures. It was also found that the annual numbers of having X-rays has increased compared to previous years.
Key words: X-ray medical diagnostic procedures, number and types of X-ray examinations STRESZCZENIE
Wprowadzenie. W placówkach służby zdrowia powszechnie wykorzystywane jest promieniowanie jonizujące w celach medycznych zarówno w diagnostyce jak i terapii. Promieniowanie to nie jest jednak całkowicie obojętne dla zdrowia. Cel. Celem niniejszych badań było określenie i ocena liczby i rodzaju wykonywanych na terenie województwa mazowiec-kiego procedur medycznych z zakresu diagnostyki ogólnej, stomatologii, mammografii i tomografii komputerowej, osobno dla dzieci, kobiet i mężczyzn.
Materiał i metody. Szacowanie liczby badań rentgenowskich przeprowadzono metodę ankietową. Zbierano dane liczbowe z placówek służby zdrowia przy wykorzystaniu opracowanej w tym celu ankiety. Ankiety przekazywano listownie do wy-losowanych placówek służby zdrowia na terenie województwa mazowieckiego lub proszono o ich wypełnienie w trakcie przeprowadzania specjalistycznych testów parametrów fizycznych medycznych aparatów rentgenowskich. W tym drugim przypadku weryfikowano jednocześnie zgodność danych w wypełnianych ankietach w stosunku do zapisów w prowadzo-nych rejestrach badań pacjentów w pracowniach rentgenowskiej.
Wyniki. Oszacowano, iż w 2009 roku na obszarze objętym niniejszymi badaniami wykonano łącznie 7612046 diagno-stycznych badań rentgenowskich, co daje 1460 badań na 1000 mieszkańców. Najwięcej badań przeprowadzono u kobiet 3847961 (50.55 %), w dalszej kolejności u mężczyzn 3193781 (41.96 %) i dzieci 570304 (7.49 %).
Wnioski. W wyniku przeprowadzonych analiz stwierdzono, iż największy udział w strukturze wykonywanych badań rtg miały procedury medyczne z zakresu diagnostyki ogólnej, w tym przede wszystkim badania klatki piersiowej. Na drugim miejscu znajdują się badania rentgenowskie stomatologiczne, głównie wewnątrzustne (punktowe). W dalszej kolejności pod względem liczby wykonywanych badań rtg uplasowały się procedury medyczne z zakresu tomografii komputerowej,
wśród których dominowały badania tomograficzne CT głowy oraz procedury medyczne związane z badaniami mammogra-ficznymi. Zaobserwowano wzrost liczby wykonywanych rentgenowskich procedur medycznych w odniesieniu do danych z wcześniej prowadzonych tego typu badań na terenie Polski.
Słowa kluczowe: rentgenowskie procedury medyczne, liczba i rodzaje badań
INTRODUCTION
Since time immemorial, mankind has always been exposed to ionising radiation from natural sources. Ho-wever since the discovery of radioactivity by Becquerel and subsequently X-rays by Rontgen [8], humans have also been exposed to ionising radiation from artificial sources. For the study purposes, it is assumed that expo-sure to ionising radiation from such artificial sources constitutes 26.2% of the total radiation exposure for the average Polish person, of which the majority originates from medical/healthcare interventions.
Making a medical diagnosis often requires exa-mining a patient using X-ray techniques which is not without its attendant health risks. It is thus important to know how many X-rays were done on a population per given period, in order to estimate the received dose of radiation. Based on such considerations, the cancer risk can be evaluated resulting from radiation exposure to artificial sources using IRCP and BEIR models [1, 6]. In Poland such radiation exposure data has only been available for the last 10-12 years [7, 13]. Hitherto, not only has the construction of X-ray units changed, but also X-rays have become more popular and more easily available. Moreover, the advent of new technologies has changed the types now used eg. X-ray computer tomography. As a result, nowadays it is important that the number of X-ray examinations undergone should be monitored for any given population. The presented study provides estimates on the number of X-rays un-dertaken in the Polish province of Mazovia.
MATERIAL AND METHODS
The primary tool of the survey was a questionnaire, designed and separately tailored for children, women or men living in the Mazovian region of Poland. This inc-luded a main question put to all subjects, on the number of X-rays undergone for the following purposes; general diagnoses, dental radiographs, mammography or computer tomography. Each of these diagnostic procedures were then sub-divided into more detailed questions as now described. For making general diagnoses, questions on the following X-rayed areas were posed; head, spine (cervical, thoracic, and lumbo - sacral regions), chest, abdomen, pelvis, urina-ry tract, limbs, (hands, elbows, shoulders, femurs, knees and feet). Questions on dental radiographs concerned the
intraoral, panoramic or cephalometric areas. For computer tomography, these regarded examinations of head, chest, abdomen, pelvis or lower limbs. Mammography was also included in the questionnaire as well as questions on other X-ray examinations not mentioned as above.
For the survey, medical centres providing health-care were selected at random and which then received the same number of questionnaires, irrespective of the types of X-ray performed. Questionnaires were sent by mail to 30% of all medical units within the Mazovian region that had X-ray rooms intended for performing general diagnoses, dental radiographs, mammography or computer tomography. They were also completed by X-ray operators during quality control testing. The ray operators were asked to give the number of X--rays performed, per single X-ray unit, over the month of May in 2009 for all the aforementioned types of exa-minations. The reason for deliberately choosing May, was that it is considered to be the most representative month of the year, as had been previously established with the X-ray specialists from Mazovia.
The average number of X-rays done per exami-nation type were thus estimated as well as the total number of X-rays performed in the entire Mazovian region (taking into account the numbers of X-ray units and of X-rays done per single unit). Non-residents of Mazovia were not included, which made up around 2% of the total X-rays performed. From this data, the number of X-rays per 1000 people living in Mazovia were estimated for the most important X-ray medical procedures based on patient’s gender and age [9].
RESULTS AND DISCUSSION
Out of the 530 questionnaires sent, replies/feed-back were received from 204 (38.49%). The data thus demonstrated that 7207413 X-rays had been performed during 2009. This works out as 1460 X-rays per 1000 persons, given that the population of the Mazovian pro-vince is 5207413 [10]. X-ray data for particular types of examinations and their percentage share are presented in Figures 1 and 2. Tables 1, 2 and 3 show data for the number of X-ray examinations per 1000 citizens divided according to patient group; children, women and men. Figure 1 demonstrates that the majority of X-rays performed were for general diagnostic examinations; 5596057 (73.52%), including Chest AP and LAT (shown in
Figure 2); 2202747 (28.94%). Data for dental radiographs (Figure 1) showed that 1420634 (18.65%) X-rays had been done, especially the intraoral ones 1228610 (86.48%), as presented in Table 2. There were 400027 (5.26%) X-rays performed in computer tomography (CT) are presented in Figure 1, where the most popular were head examinations, as shown in Table 3; 199920 (49.98%). Numbers of X-rays taken for mammography (Figure 1) were 195328 (2.57%). It should of course be noted that none of the X-ray rooms reported conducting mammography on men. Data from Table 1 indicate that women are X-rayed more frequently than men, especially for spinal examinations; 687971 (57.50%) and Chest AP and LAT; 1087862 (49.39%). In comparison, there were 1003322 (45.55%) chest X-rays done on men. It was also found that women had more X--rays of limbs than men, respectively; 491087 (44.05%) and 451643 (40.50%), whereas for children the numbers were 172304 (15.45%). Likewise, many more women
than men, had dental radiographs performed, respectively; 722621 (50.87%) and 568128 (39.99%), with children at 129885 (9.14%). It was only in computer tomography (Table 3) that the number of X-rays were higher for men than women and children, respectively; 200060 (50.03%), 182188 (45.57%) and 17594 (4.40%).
It is also worthwhile noting the X-ray results from previous years in the Mazovian province so that pro-gressing changes can be observed; with the qualifica-tion that data from one district were missing. The last analysis had been performed in 2004, which covered all provinces of Poland and demonstrated 830 X-rays per 1000 persons [12]. Some of these included using now obsolete procedures such as photofluorography, which has subsequently been shown to bear a significant radiation risk to the patient. Although the current study represents the largest province of Poland, the authors have made extrapolations to the rest of the country, Figure 1. The number of X-rays performed in the Mazovian province of Poland according to examination type
Table 1. The sub-divisional structure of the general diagnoses procedures with corresponding incidences of performed X-rays observed in the Mazovian province (for 2009).
Type of
X-ray examination X-ray medical procedure Groups of patients
Number of X-ray examinations in 2009 Number of X-rays performed per 1000 in a group of patients Number of X-rays performed per 1000 citizens Total number of X-ray examinations General diagnostic
Head AP ChildrenWomen 22 49975 367 2533 36 185 815
Men 87 949 43
Head LAT ChildrenWomen 13 20260 864 1427 29 149 867
Men 75 801 37
Cervical spine ChildrenWomen 146 4576 260 647 47 243 951
Men 91 234 45
Thoracic spine AP/PA ChildrenWomen 10 72272 764 1232 26 134 867
Men 51 381 25
Thoracic spine LAT ChildrenWomen 66 9383 099 293 23 118 257
Men 48 220 24 Lumbo-sacral spine AP Children 11 156 12 70 367 165 Women 210 172 92 Men 145 837 72 Lumbi-sacral spine LAT Children 5 764 6 64 332 147 Women 191 640 84 Men 134 743 66
Chest AP ChildrenWomen 107 534881 595 118387 348 1 817 545
Men 828 416 408
Chest LAT ChildrenWomen 206 2674 029 904 74 385 202
Men 174 906 86
Abdomen AP ChildrenWomen 45 4935 268 206 20 105 117
Men 54 356 27
Pelvis AP ChildrenWomen 75 6779 297 1033 25 130 777
Men 45 803 23
Urinary tract ChildrenWomen 10 660682 15 5 25 907
Men 14 565 7
Urinary tract with contrast
Children 2 975 3
9 46 608
Women 17 540 8
Men 26 093 13
Hand ChildrenWomen 49 95587 825 5539 45 233 290
Men 95 510 47
Elbow ChildrenWomen 15 74330 618 1713 15 79 272
Men 32 911 16
Shoulder ChildrenWomen 34 15154 356 3724 28 144 412
Men 55 905 28
Femur ChildrenWomen 15 92945 245 1720 22 116 398
Men 55 224 27
Knee ChildrenWomen 152 90318 966 2167 54 279 775
Men 107 906 53
Food ChildrenWomen 120 24037 560 4153 50 261 988
Men 104 187 51 Other X-ray examinations Children 48 034 53 84 437 699 Women 195 111 86 Men 194 553 96
Total number of X-ray examinations: 5 596 057
Number of citizens: 5 222 167 • Children (0-16 years old) 911 364 • Women 2 280 436 • Men 2 030 367
with the proviso that the incidence of X-raying made per 1000 persons are not necessarily replicated in other areas/provinces. Reasons for this being so, are the non-uniform availability of X-ray rooms and differing numbers of X-ray units; the former being an important factor for computer tomography and mammography [2]. In 2009 it was estimated that 1150 X-rays were perfor-med per 1000 person in total, which when compared to previously recent years, shows an increase. During 1991 – 1996, there were 641 X-rays done per 1000 persons [14] rising to 830 X-rays per 1000 persons [12]. These Polish results are generally comparable to rates found
in other European countries, however these may some-times be unreliable as such data is not always regularly published and might be only available for certain past years. A French study indicated that in 2002 there were from 977 up to 1179 X-rays done per 1000 citizens [11] with a tendency to increase [14]. In 2008, from the UK there were 752 X-rays performed per 1000 citizens [5] which represented a 54% increase from previous years 1991-1996. Germany demonstrated rates of 1254 X-rays per 1000 citizens in years 1991-1996 [14].
As emphasised in the introduction, it is vital to regularly monitor the number of X-ray treatments as it Table 2. The sub-divisional structure of the X-ray dental and mammography procedures with corresponding incidences of
performed X-rays observed in the Mazovian province (for 2009).
Type of X-ray examination
X-ray medical
procedures Groups of patients
Number of X-ray examinations in
2009
Number of X-rays performed per
1000 patients
Number of X-rays performed per
1000 citizens
Dental radiographs
Intraoral ChildrenWomen 639 137 88 845 140280 234
Men 500 628 247
Panoramic ChildrenWomen 34 020 78 624 7234 34
Men 63 720 31
Cephalometric ChildrenWomen 7 020 4 860 152 3
Men 3 780 2
Total number of X-ray examinations: 1 420 634 • Intraoral: 1 228 610 • Panoramic: 176 364 • Cephalometric: 15 660
Number of citizens: 5 222 167
• Children (5-16 years old) 632 960 (Intraoral) • Children (7-16 years old) 535 944 (Panoramic) • Women 2 280 436
• Men 2 030 367
Mammography Women 195 328 285 37
Total number of X-ray examinations: 195 328 Women aged 50-69 years: 685 927
Table 3. The sub-divisional structure of the computer tomography procedures with corresponding incidences of performed X-rays observed in the Mazovian province (for 2009).
Type of
X-ray examination X-ray medical procedures Groups of patients
Number of X-ray examinations in 2009 Number of X-rays performed per 1000 patients Number of X-rays performed per
1000 citizens
Computer tomography
CT Head ChildrenWomen 13 62791 047 2240 38
Men 95 247 47
CT Chest ChildrenWomen 1 26022 167 10 2 10
Men 28 653 14
CT Abdomen ChildrenWomen 32730 100 113 13
Men 35 840 18
CT Pelvis ChildrenWomen 93 6 580 3 - 2
Men 4 993 2
CT lower limb ChildrenWomen 1 587 187 1 - 1
Men 1 447 1 Other CT examinations Children 2 100 3 13 Women 30 799 13 Men 33 973 17
Total number of CT examinations: 400 027 • CT Head: 199 921 • CT Chest: 52 080 • CT Abdomen: 66 267 • CT Pelvis: 11 666 • CT lower limb: 3 221 • Other CT examinations: 66 872 Number of citizens: 5 222 167 • Children (5-16 years old) 571 299 • Women 2 310 692 • Men 2 061 772
constitutes a starting point for estimating cancer risk in any given population resulting from exposure to ionizing radiation. To achieve this, the best method is by surveying Healthcare Service Providers via a questionnaire. Data so received, may not however be completely accurate due to the following reasons; results from one month extrapola-ted to a whole year, the percentage of received answers and how correctly were questionnaires completed - it being possible to verify the latter by a scheduled quality test control. The questionnaire data were also compared to entries from the X-ray rooms’ register, per given patient, and no major discrepancies were reported. It was also necessary to randomise the choice of medical centres providing health care so as to assure the diversity of the received data (both from central hospitals as well as from single X-ray rooms with only one X-ray unit available). The total uncertainty of the obtained results should not be higher than 14% [12]. It also worth mentioning that X-ray examinations in the Mazovian district were done by 1067 X-ray unit operators [9], in dental radiography by 6586 dentists, whilst 363 radiologists issued reports on results from X-ray films and radiography [3].
CONCLUSIONS
1. In 2009, there were 7612046 X-rays performed in the Mazovian district, equivalent to 1460 X-rays per 1000 persons.
2. Results indicate that the dominating medical proce-dure was for general diagnoses (73.52%), followed by dental radiography (18.65%), computer tomogra-phy (5.26%) and mammogratomogra-phy (2.57%).
3. The most popular X-ray diagnostic procedure in the Mazovian district were chest radiography exami-nations 2207747 (28.94 %) and spinal radiography 1196387 (15.72 %).
4. The majority of X-rays were done on women 3847961 (50.55 %) compared to men 3193781 (41.96 %) and children 570304 (7.49%).
Acknowledgements
This study has been financed by the National Center of Science as research projects: “Radiation risk from X-ray diagnostic procedures and cancer risk in the Mazovian district”(No N N404 109339) and “Impro-vement of safety and conditions of work” (CIOP-PIB, 2011-2013, NCRD)
REFERENCES
1. BEIR VII Phase 2: Health risk from exposure to low levels of ionizing radiation. National Academy Press, 2006.
2. Bekas M., Pachocki K. A., Różycki Z., Wieprzowski K., Fabiszewska E.: Evaluation of mammographic units in Poland in the view of current requirements of ra-diation protection regulations. Rocz Panstw Zakl Hig 2006;57(1):81-90 (in Polish).
3. Statistical Bulletin of the Ministry of Health, Warsaw, 2010 (in Polish).
4. Activities of the president of the National Atomic Energy Agency and assessment of nuclear safety and radiation protection in Poland in 2011. Państwowa Agencja Ato-mistyki, Warszawa, 2012 (in Polish).
5. Hart D., Wall B.F., Hillier M.C., Shrimpton P.C.: Frequ-ency and Collective Dose for Medical and Dental X-ray Examination in the UK, 2008. Report HPA-CRCE-012, HPA,2010.
6. ICRP Publication 103: The 2007 Recommendations of the International Commission on Radiological, Annals of the ICRP 37 (2-7), 2007.
7. Jankowski J.: Assessment of risk of cancer in Polish population as a result of the use of X-ray in medicine. Papers on the degree of habilitated doctor. Instytut Me-dycyny Pracy, Łódź 1980 (in Polish).
8. Leszczyński S.: History of Polish radiology in relation to world radiology. Medycyna Praktyczna, Kraków 2000 (in Polish).
9. Mazovian Provincial Office, Department of Social Po-licy, Medical Statistic Branch. Evaluation of the health status of Mazovian province population. Warsaw, 2010 (in Polish).
10. Demographic Yearbook. Central Statistical Office, War-saw, 2010 (in Polish).
11. Scnaff P., Donadieu J., Pirard P., Aubert B.: Population exposure to ionizing radiation from medical examination in France. Br J Radiol 2008;81:204-213.
12. Staniszewska M. A., Papierz S.: Diagnostic X-ray exami-nations in Poland in 2004 in view of the population expo-sure: the structure and trends. Med Prac 2006;57(3):251-256 (in Polish).
13. Staniszewska M.A.: X-ray diagnostic as risk factor for Polish population in 1986 and 1995. Papers on the degree of habilitated doctor. Instytut Medycyny Pracy, Łódź, 2000 (in Polish).
14. United Nations Scientific Committee on the Effects of Atomic Radiation, Sources and effects of ionizing radia-tion. United Nations, New York, 2000.
Received: 06.12.2012 Accepted: 11.04.2013
